QAPI and Antimicrobial Stewardship Paul Mulhausen, MD Nell Griffin, - - PowerPoint PPT Presentation

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QAPI and Antimicrobial Stewardship Paul Mulhausen, MD Nell Griffin, - - PowerPoint PPT Presentation

Apr 20, 2023 36 likes •403 views

QAPI and Antimicrobial Stewardship Paul Mulhausen, MD Nell Griffin, Sr. QIF Telligen QIN-QIO Employee-Owned Employee-Owned Program Objectives You will recognize the challenges and practice patterns in LTC that uniquely inform improvement

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Employee-Owned

QAPI and Antimicrobial Stewardship

Paul Mulhausen, MD Nell Griffin, Sr. QIF Telligen QIN-QIO

Employee-Owned

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Program Objectives

  • You will recognize the challenges and practice patterns

in LTC that uniquely inform improvement opportunities for antimicrobial stewardship.

  • You will bring best practices in antimicrobial

stewardship to inform a QAPI Project Plan and Monitoring Tool.

  • You will implement a QAPI PIP that enhances

antimicrobial stewardship in your setting.

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Presentation Organization

  • Brief Review of the Problem and Opportunity
  • The nature of antimicrobial use in long term care

institutional settings

  • Highlight similarities of antimicrobial stewardship core

elements and QAPI – integrating antimicrobial stewardship into your QAPI program

  • Discuss unique challenges to stewardship in LTC settings
  • Highlight bacteriuria management using resources from

the AHRQ NH Stewardship Guide as a QAPI PIP

  • pportunity for antimicrobial stewardship.
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Review of the problem

  • Antibiotic resistance is one of the three greatest

threats to health in the US!

– 23,000 deaths each year from resistant infection – 250,000 C. difficile infections (CDI) each year – 75% of CDI occur in nursing homes and other community settings

  • Antibiotic resistance is one of the greatest threats to

health in the world!

  • 700,000 die of resistant infection
  • Predictions rise to 10-million by 2050
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Fighting Antimicrobial Resistance

1. Prevent Infections and Prevent Spread 2. Track antibiotic-resistant infections 3. Antimicrobial Stewardship 4. Develop New Drugs and Diagnostic Tests

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Fighting Back in LTC

  • Huge opportunities for

stewardship

  • 43% of residents are colonized

with resistant microorganisms

  • Every six months 42% of

residents receive an antibiotic.

  • 25% to 75% of the antimicrobial

prescriptions may not meet guidelines

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Core Elements of an Antimicrobial Stewardship Program

  • Leadership commitment
  • Accountability
  • Drug expertise
  • Action
  • Tracking
  • Reporting
  • Education
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Antimicrobial Stewardship and QAPI

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Unique Challenges in LTC

  • The antibiotic prescribing process in nursing homes is

complex and differs from the prescribing process in hospital and clinic settings. – A process – Family preferences are influential – Often a telephone consultation

  • Influenced by nursing staff input
  • Influenced by inter-professional communication

– Limited clinical and laboratory information

  • Vulnerable population
  • Challenging symptom communication
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What works in Long Term Care Institutions?

  • Educational Materials for clinicians, staff, and

residents

  • Education Materials for prescribing clinicians with

prescribing pattern feedback

  • Locally developed guidelines for clinicians
  • Help staff and prescribers avoid over-diagnoses of

urinary tract infections

  • Antimicrobial stewardship tool for staff
  • Post-prescribing Review and de-escalation
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UTI Overdiagnosis: A place to start

  • Suspected UTI accounts for 30%-50% of antibiotics

prescribed in LTC

  • Up to one-third of antibiotics used for UTI are for

asymptomatic bacteriuria (ASB)

  • Half of LTC residents have ASB
  • ASB is benign in LTC residents
  • Treating ASB does not improve outcomes
  • Treating ASB with antibiotics causes ADEs
  • Preventing the overtreatment of ASB holds promise for a

QAPI Process Improvement Process (PIP)

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Choosing Wisely: AMDA & AGS

  • “Don’t obtain a urine culture unless there

are clear signs and symptoms that localize to the urinary tract.”

  • “Don’t use antimicrobials to treat

bacteriuria in older adults unless specific urinary tract symptoms are present.”

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Preventing UTI Overdiagnosis

  • Practice Guideline: The Loeb Criteria
  • Communication Tools: The Suspected UTI SBAR
  • Staff education: Asymptomatic bacteriuria
  • Resident and Family Engagement:

– Asymptomatic bacteriuria – Educate about role of “culture for cure”

  • Tracking Measures

– UTI by Loeb or McGeer Criteria – Antibiotic use rates for UTI

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Suspected UTI SBAR

https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T1-SBAR_UTI_Final.pdf

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Staff Education: Not all infections need antibiotics!

https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T3-Not_all_Infections_need_antibiotics-_final.pdf

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Patient and Family Engagement

https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T5- Suspect_a_Urinary_Tract_Infection_brochure_MA_Coalition_final.pdf

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AHRQ tools to support tracking

https://www.ahrq.gov/nhguide/toolkits/implement-monitor-sustain-program/toolkit2-monitor-sustain-program.html

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AHRQ NH Stewardship Guide

  • https://www.ahrq.gov/nhguide/index.html
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Resources to Get You Started

  • https://www.cdc.gov/getsmart/
  • https://www.cdc.gov/longtermcare/prevention/antibi
  • tic-stewardship.html
  • https://www.ahrq.gov/nhguide/index.html
  • https://www.cdc.gov/getsmart/healthcare/implement

ation.html

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Get started with QAPI for antimicrobial stewardship

  • LTC settings present great opportunity to

fight antimicrobial resistance and CDI.

  • Antimicrobial stewardship presents one of

the largest opportunities for LTC settings

  • Antimicrobial stewardship structure is nicely

supported by QAPI framework.

  • Resources are available to support your

antimicrobial stewardship PIPs.

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What is Antibiotic Stewardship?

A set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

  • Recommend all nursing homes improve antibiotic

prescribing practices

  • Recommend all nursing homes reduce inappropriate

antibiotic use

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Why QAPI?

Quality Assurance Performance Improvement (QAPI) is a data-driven, proactive approach to improving the quality

  • f life, care, and services in nursing homes.

The activities of QAPI:

  • involve members at all levels of the organization
  • identify opportunities for improvement
  • address gaps in systems or processes
  • develop and implement an improvement plan
  • continuously monitor effectiveness of interventions

.

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Why Antibiotic Stewardship for Nursing Homes?

  • Among the most commonly

prescribed medications

  • 40%-75% are prescribed

incorrectly

– For prevention – Before infection is confirmed – For colonized bacteria

  • Poor communication during

transfers

  • Antibiotic harm such a C.

difficile can be severe.

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Why Antibiotic Stewardship and QAPI?

To protect residents and reduce the threat of antibiotic resistance which will improve the quality of care and services.

  • Both included in the Medicare and

Medicaid Programs; Reform of Requirements for Long-Term Care Facilities

  • Both advocate for the residents
  • Both involve process improvement
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QAPI Resource

  • Guidebook to assist

with QAPI

– Implementation – Sustainment

  • 12 Action Steps

https://www.cms.gov/Medicare/Provider-Enrollment-and Certification/QAPI/Downloads/ProcessToolFramework.pdf

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Antibiotic Stewardship Resources

https://www.cdc.gov/longtermcare/prevention/ant ibiotic-stewardship.html

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QAPI Process Tools

  • Checklist
  • Worksheet
  • Templates
  • Flow charts and process maps
  • Reporting forms or outlines
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Checklist for Core Elements of Antibiotic Stewardship in Nursing Homes

  • Leadership Support
  • Accountability
  • Drug Expertise
  • Action to Improve Use
  • Tracking Monitoring Antibiotic

Prescribing, Use, and Resistance

  • Reporting Information to Staff
  • n Improving Antibiotic Use

and Resistance

  • Education
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Antibiotic Stewardship Checklist: Guiding Questions & QAPI Action Steps

  • Q 1 Leadership Support: Can your facility demonstrate leadership support

for antibiotic stewardship? – QAPI Step 1: Leadership Responsibility & Accountability – QAPI Step 5: Develop Your QAPI Plan

  • Q 2 Accountability: Has your facility identified a leader for antibiotic

stewardship activities? – QAPI Step 1: Leadership Responsibility & Accountability – QAPI Step 2: Develop a Deliberate Approach to Teamwork – QAPI Step 4: Identify Your Organization’s Guiding Principles – QAPI Step 5: Develop Your QAPI Plan

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Antibiotic Stewardship Checklist: Guiding Questions & QAPI Action Steps

  • Q 3 Drug Expertise: Does your facility have access to individual(s) with

antibiotic stewardship expertise? – QAPI Step 2: Develop a Deliberate Approach to Teamwork – QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs – QAPI Step 10: Plan, Conduct and Document PIPs – QAPI Step 11: Getting to the “Root” of the Problem – QAPI Step 12: Take Systemic Action

  • Q 4. Actions to Improve Use: Does your facility have policies to improve

antibiotic prescribing/use? – QAPI Step 1: Leadership Responsibility and Accountability – QAPI Step 4: Identify Your Organization’s Guiding Principles – QAPI Step 5: Develop Your QAPI Plan – QAPI Step 7: Develop a Strategy for Collecting and Using QAPI Data

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Antibiotic Stewardship Checklist: Guiding Questions & QAPI Action Steps

  • Q5. Action to Improve Use: Has your facility implemented practices to

improve antibiotic use?

  • QAPI Step 3: Take your QAPI “Pulse” with a Self-Assessment
  • QAPI Step 6: Conduct a QAPI Awareness Campaign
  • QAPI Step 8: Identify Your Gaps and Opportunities
  • Q6. Action to Improve Use: Does your consultant pharmacist support

antibiotic stewardship activities?

  • QAPI Step 2: Develop a Deliberate Approach to Teamwork
  • QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs
  • QAPI Step 10: Plan, Conduct and Document PIPs
  • QAPI Step 11: Getting to the ‘Root” of the Problem
  • QAPI Step 12: Take Systemic Action
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Antibiotic Stewardship Checklist: Guiding Questions & QAPI Action Steps

  • Q7. Tracking: Monitoring Antibiotic Prescribing, Use, and Resistance:

Does your facility monitor one or more measures of antibiotic use?

  • QAPI Step 7: Develop a Strategy for Collecting and Using QAPI Data
  • QAPI Step 8: Identify Your Gaps and Opportunities
  • QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs
  • QAPI Step 10: Plan, Conduct and Document PIPs
  • QAPI Step 12: Take Systemic Action
  • Q8. Tracking: Monitoring Antibiotic Prescribing, Use, and Resistance:

Does your facility monitor one or more outcomes of antibiotic use?

  • QAPI Step 7: Develop a Strategy for Collecting and Using QAPI Data
  • QAPI Step 12: Take Systemic Action
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Antibiotic Stewardship Checklist: Guiding Questions & QAPI Action Steps

  • Q 9. Reporting Information to Staff on Improving Antibiotic Use and

Resistance: Does your facility provide-specific reports on antibiotic use and outcomes with clinical providers and nursing staff? – QAPI Step 3: Take your QAPI “Pulse” with a Self-Assessment – QAPI Step 6: Conduct a QAPI Awareness Campaign – QAPI Step 7: Develop a Strategy for Collecting and Using QAPI Data

  • Q 10. Education: Does your facility provide educational resources and

materials about antibiotic resistance and opportunities for improving antibiotic use? – QAPI Step 1: Leadership Responsibility and Accountability – QAPI Step 5: Develop Your QAPI Plan

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Resources

Telligen QIN-QIO https://telligenqinqio.com/ National Nursing Home Quality Improvement Campaign https://nhqualitycampaign.org/ CDC Core Elements of Antibiotic Stewardship for Nursing Homes https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html CDC Core Elements of Antibiotic Stewardship for Nursing Homes CHECKLIST https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf CDC Core Elements of Antibiotic Stewardship Appendix B: Measures of antibiotic prescribing use and outcomes https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-b.pdf AHRQ Nursing Home Antimicrobial Stewardship Guide https://www.ahrq.gov/nhguide/about/index.html National Nursing Home Quality Improvement Campaign C. difficile & Antibiotic Stewardship https://www.nhqualitycampaign.org/cdifficileAntibioticStewardship.aspx

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Employee-Owned

Your Turn

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Please Contact any of our Quality Innovation Network Representatives to Learn More

Lisa Bridwell lisa.bridwell@area-d.hcqis.org 630-928-5831 Nell Griffin nell.griffin@area-d.hcqis.org 630-928-5813 Larpie Castro larpie.castro@area-D.hcqis.org 630-928-5812 Linda Savage linda.savage@area-d.hcqis.org 303-513-2323 Deanna Curry deanna.curry@area-d.hcqis.org 720-554-1479 Kristen Ives – NHSN support kristen.ives@area-d.hcqis.org 720-554-1695

This material was prepared by Telligen, the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

  • Services. The contents presented do not necessarily reflect CMS policy. 11SOW-

QIN-C2-07/27/17-2233